- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.14 / $1,448.18 / $8,853.15
| Professional | | $303.14 | $1,448.18 | $8,853.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.63 / $430.63 / $430.63
| Facility | | $430.63 | $430.63 | $430.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.81 / $430.63 / $2,726.21
| Professional | | $352.81 | $430.63 | $2,726.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.63 / $3,326.70 / $3,608.41
| Facility | | $430.63 | $3,326.70 | $3,608.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.55 / $1,379.26 / $2,786.21
| Professional | | $283.55 | $1,379.26 | $2,786.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.47 / $1,650.47 / $6,295.00
| Facility | | $1,650.47 | $1,650.47 | $6,295.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,408.64 / $2,779.20 / $4,098.66
| Professional | | $2,408.64 | $2,779.20 | $4,098.66 |